For all the uncertainty over the fate of a health care overhaul in Washington, tens of thousands of Montana's working poor are already in a double quandary: Even if Congress leaves Medicaid expansion mostly intact, the future of the state's program remains uncertain.

Gov. Steve Bullock, who counts Medicaid expansion as a key achievement in his first term, has less than two years to justify its continuation. The program is scheduled to end in 2019 if state lawmakers decline to renew it during the legislative session that starts in January of that year.

Among the 31 states with expanded Medicaid, Montana's program is unique. As part of a grand bargain to placate moderate Republicans in the conservative-leaning state, Bullock and his fellow Democrats agreed to charge most enrollees premiums and co-pays, establish a jobs program intended to help able-bodied Medicaid recipients find good-paying work, and seek reauthorization.

While Montana Democrats tout their state's plummeting number of medically uninsured — from 20 percent of the population in 2013 to 7 percent last year — the number of Medicaid enrollees has far exceeded expectations, and some worry the program cannot be sustained.

Since it took effect in January of last year, nearly 80,000 of Montana's 1 million residents have enrolled. The state had projected only 33,000 by this time.

A U.S. Senate bill to replace the Obama administration's health care law would phase out, over several years, the federal money given to states to expand Medicaid. That might not be soon enough for conservative Montana lawmakers who are eager to revisit the expansion program when the session reconvenes in 2019.

"So, is this thing really working?" said state Sen. Bob Keenan, a Republican from the western Montana town of Bigfork. "I'm from the state of Missouri at this point in time — show me."

Keenan and other critics are skeptical the state is doing enough to get people into jobs — and off Medicaid — in the program's second year.

"The spin right now is that conservative Republicans are going to take something away," Keenan said. "That's not me. For now, I'm just sitting back and waiting to see if they can justify the program."

Even the lead sponsor of the bill that authorized expansion is raising concern that the higher-than-expected number of enrollees could be unsustainable and that state officials need to be more aggressive with the program's job training component.

"They promised that they would make it work," said Republican state Sen. Ed Buttrey of Great Falls. "And if they don't, then the program needs to change, or there will be a great risk that it could go away."

That's an unsettling prospect for Tammie Jackson and her husband, Travis, both of whom rely on Medicaid for health coverage.

For years, both were uninsured. Travis is on traditional Medicaid because of diabetes-related disabilities. He's been unable to work because of severe nerve damage in his hands and feet.

Tammie Jackson makes a modest living cleaning hotel rooms in the mining town of Butte, a working class-community where about a tenth of the 34,000 residents are enrolled in the expansion program.

She's held the same job for 26 years, but it didn't come with health insurance. For most of that time, she did without.

She qualified for Medicaid under the expansion last year. It provides the specialists to treat her for Asperger's and anxiety, and for the cyst they found in her uterus. She also wrenched her back a month ago and is doing physical therapy so she can return to work.

"Without Medicaid expansion, she wouldn't be able to get any physical therapy she needs so she can start getting a paycheck again," said Travis Jackson, who often speaks on his wife's behalf because she can sometimes feel socially awkward around people she doesn't know.

The Jacksons have watched with concern as the health care debate unfolds.

About two-thirds of Medicaid expansion enrollees already have jobs. However, those jobs lack health benefits, and the wages are too meager to pay for private coverage — a reality far too common in rural economies.

Bullock's office said more than 12,000 Medicaid enrollees have gotten employment services through the Department of Labor and Industry.

The agency considers the workforce component a success, even if the number of participants is just a sliver of what was anticipated. State officials initially expected 75 percent of Medicaid expansion enrollees would avail themselves of job services, which translates to about 60,000 would-be job seekers. But given little additional new resources, that goal may have been unreasonable from the start.

Nevertheless, said department spokesman Jake Troyer, "We're training new people to come into the workforce, and we're giving people opportunities to upscale their employment."

Troyer could not immediately say, however, how many people his agency helped get off Medicaid because they landed better jobs.

John Goodnow, CEO of Great Falls' Benefis Health Systems, said the public must be better informed about the people who have been helped if the program is to survive after 2019.

"What we have to do better is demonstrate the positive impact it's had to our state, to our economy, and not just in human interest terms — and there are lots of those — but also in terms of dollars and cents," said Goodnow, who chairs Montana's Medicaid expansion oversight committee. "And we need to work on that now."

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